As The Wrench Turns - Failure to Launch, Lessons Learned from John Goglia

Some days start out perfectly fine. Nice weather, uneventful night – i.e. no emergencies and no pressure. This particular day was one of those days. A good morning to be out working the ramp at Logan. Notice I said start out fine. I didn’t say end up just fine. But I get ahead of myself.

I was the mechanic assigned to launch the Convair 580 aircraft on its first flight of the day. I had been working this job long enough to know the routine. Power on the aircraft, make sure the instruments are powered up, the gyros come up to speed, check fluid levels, oxygen levels; in short look at everything the pilot would look at during his (and it was his in those days) pre-flight so you didn’t get any surprises.

My tasks completed, I headed back into the line shack to wait for the passengers to be boarded, the baggage loaded and the aircraft fueled. All part of the routine. Mechanics did the pre-launch items to ensure the aircraft was mechanically ready for an on time departure. Others were responsible for the rest. Nothing complicated about this routine. Except on this day, something went very wrong. 

Within a few minutes of the fueler hooking up and starting to fuel the aircraft, he came running in to report a fuel leak. Fuel was spewing out of the rivets on the underside of the wing. I rushed out to see what was happening, along with another mechanic on duty. From the rate of flow, it was obvious to us that this was a serious fuel leak and the aircraft would have to be defueled to stop the leak. 

Once the aircraft was defueled, we opened one of the wing access panels nearest the fuel leak. One look and we knew that there was extensive damage and this aircraft wasn’t going anywhere that day. The aircraft was then towed to the hangar to await engineering and maintenance management to arrive from corporate HQ in Pittsburgh. I wasn’t too worried at this point since I wasn’t the one fueling the aircraft and the routine procedure made it the fueler’s responsibility. 

Soon enough the suits arrived and determined that the wing had pressurized during fueling, probably as a result of the fuel pressure on the truck being set too high. I was still feeling pretty smug because, after all, I was in the line shack when the aircraft was improperly fueled. Not my fault. Well, that smug feeling did not last too long. Pretty soon I was summoned to the manager’s office and handed a letter of investigation, regarding my involvement in the events leading up to the damage to the aircraft. So, at this point, I did start to have some misgivings. But not a lot since I thought our procedures on the ramp were clear to everyone.

Several weeks later, after the aircraft was repaired, I was called back into the manager’s office for a formal meeting.  At this point, I knew things were going to get ugly. I was informed that the investigation had determined that I was at fault for the damage to the aircraft. Not words a mechanic ever wants to hear. Seems I had failed to follow the refueling manual which required the mechanic to monitor every step of the refueling process. Even though this was not the routine practice followed by every mechanic at that airline, it was clearly what the manual stated.

I reluctantly accepted the letter of reprimand I was handed. 
 

Moral of the Story: When performing any maintenance function, we are responsible for all the procedures in all the manuals, not just the maintenance manual but any operating manual, even if the manual is seldom used or difficult to access. (Of course, a better practice is to have all those responsibilities cross-referenced, but I’m not making excuses.)

Comments

Thanks John, This ties in with last weeks topic of Normalization of Deviance (http://www.askbob.aero/content/normalization-deviance). How many of us regularly review all the operations and safety manuals, procedure manuals, maintenance manuals, etc for tasks we perform every day. How easy is it for SOP (short for we have always done it that way) to differ from the written procedure.

Seems like something missing here. Why wasn't there an assigned mechanic to the job? If there was one where was he? usually fueling is a real safety issue around aircraft and the operator has to show compliance with the proper safety procedure. I would not have expected just any mechanic to take the position, I would have expected this to be assigned to a mechanic that has been through the various review on the procedures, certified and signed off and if he wasn't there where was his certified backup???
Sometimes management slips to you know.